Saturday, September 19, 2015

Attempts
to recover organisms from non-inflamed tonsils were carried out for over seven
decades. Some studies failed to find any microorganisms and others recovered
them only in a portion of the cases. Only three studies identified bacteria in
all sinus sample.

Brook evaluated the microbiology of maxillary sinuses of 12
adults and found an average of 4 isolates/sinus of aerobic and anaerobic bacteria. The
predominant anaerobes were PrevotellaFusobacterium
,and Peptostreptococcus spp., and
Propionibactreium acnes. The most
common aerobic bacteria were beta-hemolytic Streptococcoci, Staphylococcus aureus, Streptococcus pneumoniae, and Haemophillus parainfluenzae.

Ramakrishnanet al. collected middle meatus specimens from 28 individuals with no sinusitis.
Bacterial colonization was assessed in these specimens using quantitative PCR
and 16S rRNA pyrosequencing. All subjects were positive for bacterial
colonization of the middle meatus. S. aureus, S. epidermidis and P. acnes were
the most prevalent and abundant microorganisms detected. The authors found rich
and diverse bacterial assemblages in all of the individuals, including
opportunistic pathogens typically found in the nasopharynx.

Aurora et al. compared the microbiome and immune response from 30 patients with
chronic rhino-sinusitis (CRS) and 12 healthy controls. The microbiome was
analyzed by deep sequencing of the bacterial 16S and fungal 18S ribosomal RNA
genes. Although quantitative increase in most bacterial and fungal species was
observed in patients with CRS relative to controls, the microbiomes of patients
with CRS were qualitatively similar to the controls. The predominate aerobic
organisms were Cyanobacterium ,
Curtobacterium, and Pseudomonas spp., and staphylococcus
aureus. The commonest anaerobes were Propionbacterium,
and Prevottela spp.

Patients
with CRS had increased levels of the following cytokines: IL-4, IL-5, IL-8, and
IL-13, along with increased levels of eosinophils and basophils in the lavage.
Furthermore, peripheral blood leukocytes obtained from some patients with CRS
responded to control lavage samples (ie, to commensals) to produce IL-5. In
contrast, the same lavage sample evoked no IL-5 production in leukocytes from
healthy controls. These results may explain why systemic steroid treatment
provides relief for some patients with CRS.

Colonization
of non-inflamed “normal “ sinus is possible because there is direct
communication between the sinuses nasal cavity through the ostia which could
enable organisms that reside in the nasopharynx to spread into the sinus. The
presence of bacteria in the sinus can explain why following closure of the
ostium, these organisms may become involved in the emerging inflammatory
process.

The
study by Aurora et al. that the host response or lack of response to the normal
sinus flora may be key to the development of sinus inflammation. Modulation the
sinus flora by topical antimicrobial and/or probiotic organisms that may
interfere with the growth of pathogens may be used to prevent and treat sinus inflammation. Future studies that would explore these
modalities are warranted.

Wednesday, April 1, 2015

The
American Academy of Otolaryngology—Head and Neck Surgery Foundation has
published an updated “Clinical Practice Guideline: Adult Sinusitis” as a
supplement to Otolaryngology–Head and Neck Surgery. The guideline
recommendations address diagnostic accuracy for adult rhinosinusitis, the
appropriate use of ancillary tests to confirm diagnosis and guide management
(including radiography, nasal endoscopy, computed tomography, and testing for
allergy and immune function), and the judicious use of systemic and topical
therapy. Emphasis was also placed on identifying multiple chronic conditions
that would modify management of rhinosinusitis, including asthma, cystic
fibrosis, immunocompromised state, and ciliary dyskinesia.

Acute bacterial sinus can be watchful waited without
antibiotics or be treated with an antibiotic. If a decision is made to treat
acute bacterial sinus infection with an antibiotic, amoxicillin will likely be
prescribed. A combination of amoxicillin with clavulanate for 5 to 10 days may
also be prescribed as a different treatment. If after 7 days the patient feel
worse or does not improve (whether receiving antibiotic treatment or not)
he/she should see their healthcare provider. The healthcare provider will review
the diagnosis and exclude other causes. The provider may also decide to start
or change antibiotics. To relieve symptoms, the healthcare provider may
recommend over-the-counter treatments. These include pain relievers, nasal
steroid sprays, decongestants, mucus thinners, cough suppressants, and nasal
saline rinse.

About Me

Dr. Itzhak Brook is a physician who specializes in pediatrics and infectious diseases.
He is a Professor of Pediatrics at Georgetown University Washington D.C. and his areas of expertise are anaerobic and head and neck infections including sinusitis. He has done extensive research on respiratory tract infections and infections following exposure to ionizing radiation. Dr. Brook served in the US Navy for 27 years. He is the author of six medical textbooks, 155 medical book chapters and many scientific publications. He is an editor of four and associate editor of four medical journals. He is a board member of the Head and Neck Cancer Alliance. Dr. Brook is the recipient of the 2012 J. Conley Medical Ethics Lectureship Award by the American Academy of Otolaryngology-Head and Neck Surgery.
Dr. Brook was diagnosed with throat cancer in 2006.

Disclaimer

This blog is not a substitute for medical care by medical professionals. Patients should consult with their personal physicians before making any decisions about their medical and surgical care. Physicians and other providers reading this blog should make independent, informed decisions about the care of their patients based on the individual facts and circumstances of each case.